Communication with clients experiencing stressful situations

(crisis and life losses)

NO. Name Academic Number

1. Suhaylah Hussain K Albati 38-123-0-604

2. Taghreed Mohammed Ahmed Bushalaf 39-123-0-634

3. Waad Adnan Ibrahim Alsabkah 39-123-0-600

4. Wadha Mohammed Khaled Alholibi 39-123-0-555

5. Wasayf Saad Fahd Alomayrin 39-123-0-556

6. Wedad Olyan Eid Almutairi 39-123-0-630

7. Wejdan Saleh Ebraheem Ababtain 39-123-0-526

8. Wejdan Salem Mutter Alshammari 39-123-0-592

9. Yaqin Habib J Alkhalaf 39-123-0-503

10. Zahra Ahmed Taher Almubarak 39-123-0-579

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Outline:
 Introduction
 Overview
 Encouraging Emotional Expression
 How can a nurse deal with emotional situations?
 Clinical Significance
 Literature review
 Conclusions
 Referencess

Objectives:
By the end of this research, the reader would be able to:
 Understand the communication skills needed by a nurse.
 Know the meaning of a stressful situation
 Learn how to deal with clients having grief
 Know the proper wat to communicate with clients in crisis and life losses

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 1. Introduction
When working in teams of fellow nurses and colleagues from other professions, strong
communication skills are important. It's also critical to providing patient-centered treatment. Nurses who
take the time to listen to and consider their patients' needs are better equipped to deal with problems when
they occur, which leads to better patient outcomes. Bad communication, or a lack of communication, on
the other hand, may result in patients misinterpreting instructions and failing to obey treatment protocols.
It can also cause teamwork breakdowns, which can lead to medical errors. Bad coordination during
patient transfers was found to be responsible for 80 percent of severe medical errors, according to a Joint
Commission survey. Patients who have formed an open and trusting relationship with a nurse are often
more likely to reveal the full extent of their symptoms (Kerr et al., 2020). Communication competence,
according to Arnold and Boggs' book Interpersonal Relationships: Professional Communication for
Nurses, is a primary means of maintaining a trusting, collaborative partnership, Patients and their families
benefit from a working partnership. The consistency of decisions taken, as well as the degree of patient
motivation to obey treatment guidelines and achieve desired clinical outcomes, are all influenced by
interpersonal communication skills (Shao et al., 2018).

2. Overview
2.1. Effective communication skills for nurses
Good communication for nurses means approaching and patient interaction with the aim of respecting
the patient's needs, perspectives, and opinions. This involves active listening and patient teach-back
strategies, as well as verbal and nonverbal communication skills. We'll look at ten critical communication
skills for nurses below (Kerr et al., 2020).

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 i. Verbal Communication
The value of excellent verbal communication cannot be overstated. Strive to talk with consistency,
precision, and sincerity at all times. It's also vital to understand your target audience and talk respectfully
for their age, community, and level of health literacy. Be mindful of your tone of voice if you are anxious
or upset, and don't let these feelings show in your patient interaction(Ibrahim and Ahamat, 2020). You
can do the following:
 Encourage patients to communicate by asking open questions like, “Can you tell me a bit more
about that?”
 Avoid condescending pet names like “honey” or “sweetie” and instead use the patient’s first
name or name of choice.
 Speak in clear, complete sentences and avoid technical jargon.
ii. Nonverbal Communication
Nonverbal communication elements such as facial expressions, eye contact, body language,
movements, stance, and voice tone are also important in building rapport. Smiling will make a huge
difference. Additionally, you can:
 Show interest in what the patient is saying by maintaining eye contact and nodding your head.
 Smile, but don’t stare.
 Sit down when you can, and lean forward to show you’re engaged.
 Use nonthreatening body language that conveys openness.
iii. Active Listening
Listening to consider the other person's perspective is referred to as "productive listening." It is the
highest and most successful method of listening because it necessitates total focus and commitment. This
is a valuable skill not just for clinical nurses, but also for nurse executives who want to create confidence
and loyalty among their staff. Active listening comprises both verbal and nonverbal communication skills
(Ibrahim and Ahamat, 2020).
iv. Written Communication
Efficient nurse-to-nurse contact often includes written communication skills. You will be in charge of
creating and reviewing medical records as a nurse. It's important that your reports are correct and up to
date so that your patients get the best possible treatment. Also, keep patient confidentiality in mind. Some
pointers:
 Make notes immediately following patient care so you do not forget anything.
 Write legibly and clearly, using simple language.
 Be sure to note accurate dates and times.

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 v. Presentation Skills
When it comes to “handover,” or passing patient care to another nurse, effective presentation skills are
most useful. These abilities can also aid you in clearly demonstrating your experience and expertise in a
number of workplace environments, including speaking at conferences, engaging in job interviews, and
providing case reports to physicians, among others. It's a good idea to do the following (Ibrahim and
Ahamat, 2020):
 Plan out your presentation and practice.
 Pay attention to both your verbal communication and body language.
 Add visuals to your presentation for a better explanation.
 Understand your audience and know what they want and need from the presentation.
vi. Patient Education (Patient Teach-Back)
The majority of contact between the healthcare staff and patients is handled by nurses. This involves
providing information about health conditions, diagnoses, recovery options, and drug protocols to patients
and their families. This capacity is particularly important for family nurse practitioners who offer health
and education therapy to patients and their families. Patient teach-back is a communication technique in
which doctors ask patients to repeat what they've told them. This approach increases patient
comprehension and allows patients to follow treatment instructions. Patients and their families can
become anxious or defensive as a result of a lack of understanding of facts. For instance, you might say
(Ibrahim and Ahamat, 2020):
vii. Making Personal Connections
It's important to get to know the person behind the patient. Patient-centered relationships are
important for patients to feel comfortable and at ease. Developing positive relationships with patients will
help to enhance outcomes and build trust. Here are some suggestions:
 Spend a few extra minutes with each patient every day getting to know them.
 Discover a fun fact about each of the patients.
 Show an interest in their lives and share your own experiences.
viii. Trust
It's critical for healthcare providers to earn patients' confidence by consistently listening and taking
every issue and concern seriously. It takes time to create confidence. Some patients are scared of being in
a hospital. It's important to make them feel as relaxed as possible.
Trust is something that nurse educators and leaders should also cultivate as they work to develop the
next generation of nurses. To inspire trust, nurse leaders and educators should:
 Always tell the truth.

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  Share information openly.
 Be willing to admit mistakes.
ix. Cultural Awareness
Every day, you'll most likely communicate with people from different social, cultural, and educational
backgrounds. Every patient and coworker is different, so it's crucial to be conscious and receptive to their
needs. For example, assess the patient's English proficiency and adjust your vocabulary accordingly, or
bring in a translator if necessary. With trans and gender non-binary patients, be sure to use their favored
name and pronoun(Kerr et al., 2020).
x. Compassion
Compassion is a vital communication skill in the healthcare sector. “Studies show that compassion
can assist in prompting quick recovery from acute illness, improving the treatment of chronic illness, and
relieving anxiety,” according to the Journal of Compassionate Healthcare. By putting yourself in the
patient's shoes and knowing their needs, you will have compassionate nursing care (Kerr et al., 2020).

2.2 Dealing with stressful situations in medical field

All people may experience sadness and loss at some stage in their lives. The loss may be real or
imagined, and it is the absence of anything valuable. Grief is the emotional reaction to a loss, it is the
emotional feelings connected to the loss. Nurses may be directly affected by this, or they may serve as a
support net for patients and their families who are grieving. There are common phases of grief that people
go through, but each person's experience is unique. Loss feelings are often associated with the death of a
loved one, although they can occur for a variety of reasons. People may feel sorrow and loss as a result of
a significant change, such as the loss of a job, a role, a limb, a pet, a sense of loss of power, or the loss of
loved ones. The nurse's job is to provide compassionate care to the patient and their loved ones, which
may vary from person to another It is also important for the nurse to preserve emotional resiliency in
order to give the best treatment possible to those who are grieving. (Isaacson and Minton, 2018)
In the medical field, grief and loss are normal. During these experiences, nurses must be prepared to
care for patients. A serious illness diagnosis may lead to the realization that future hopes and aspirations
may have to be postponed or abandoned. Another condition that requires the nurse to interact with
expertise and sensitivity is the death or severe injury of a loved one. Loss and sorrow follow all life
experiences, including breakup, loss of independence, chronic illness, and death. Most of us find the
subject of loss terrifying because it causes us to face our own losses as well as the inevitability of the
ultimate loss—death.
Loss and sorrow are accompanied by intense feelings that magnify the meaning of everything said or
left unsaid. Individuals who have experienced excruciatingly traumatic events will often recall the exact
words spoken by a nurse or other health care worker at the time of the case. Many years later, the most

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uncomfortable and hurtful reactions can be remembered in detail. The value of contact in such
circumstances cannot be overstated. The goal of contact during a time of loss or grief is to build a
therapeutic relationship with the client and his or her family that can be supportive while they grieve
(Dosser and Kennedy, 2014). Even a brief relationship will leave a lasting impression on the bereaved.
Nurses find it difficult to express negative feelings. Despite the fact that nurses are expected to offer
information and support to mourning patients and families, they are unprepared for these difficult
experiences (Rezaei et al., 2020).

3. Encouraging Emotional Expression

Nurses play an important role in allowing people to safely convey negative emotions. When a client is
experiencing pain or loss, expressing strong feelings will help them alleviate anxiety, reduce repetitive
thoughts (“repeated, unbidden thoughts about traumatic experiences”, and gain a greater understanding of
his or her emotional reactions. Expressing sorrow reduces loneliness and improves intimacy, as well as
eliciting beneficial responses from others (such as validation and support) and encouraging the mourner
to cope more effectively.(Norouzadeh, Anoosheh and Ahmadi, 2020)
Accepting clients' denial of grief is often the safest course of action. The bereaved may have no
emotional reaction to the loss in the first hours or days after a trauma. It could indicate a time of shock
and denial during which the bereaved is still processing the loss. The nurse's job is to recognize the
client's lack of grief speech. The client may be holding back traumatic feelings until he or she is ready to
grieve. Perhaps the bereaved person has endured a lot of anticipatory sorrow before the death, or they are
worried that emotional speech will be too much for them. Rage is another common reaction to loss. While
anger is understandable, it can be detrimental to relationships. Nurses may assist angry clients in
communicating their feelings in a positive manner.

4. How can a nurse deal with emotional situations?

Nurses and other health care professionals also feel that discussing death and dying would disrupt
peaceful clients and families. (Shao et al., 2018)Clients and family members can weep and show
emotional pain when nurses discuss these topics. Nurses can come to the conclusion that they are to
blame for the client's emotional distress. Emmanuel and colleagues5 interviewed 988 people who had less
than six months to live. In general, participants in the study felt that talking about grief was beneficial
rather than upsetting. If they talk about it or not, clients who are mourning feel emotional distress. Too
frequently, mourning people hide their pain in order to make them feel better. When the nurse brings up

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the subject of conversation, the client has the ability to communicate rather than mask his or her
discomfort.
When someone is crying, don't touch them, don't give tissues, and don't disturb with comforting
words. Consoling behaviors can inhibit the client's ability to communicate emotions. When crying ceases,
comfort may be offered. Accept the feelings that arise. Comments such as “You shouldn’t feel that way”
or “Your husband wouldn’t want you to feel that way” are judgmental and not helpful. Crying is an
important grieving reaction that may be mistaken by others. Loved ones may be concerned that a lot of
crying is a bad thing and should be avoided. Others who may be sympathetic may conclude that weeping
indicates that the mourner has been overly reminded of their sorrow. The nurse will assist by reassuring
the patient that weeping is both normal and beneficial.
Theories about grief and mourning direct the issue of "What should I say?" The nurse's answer
can be structured using Worden's six tasks of mourning. The mourner's first task after a loss is to "accept
the truth of the loss. "Acknowledgement comes in stages that can take days, weeks, months, or years. On
one level, a family member may assume that a loved one has died, but on another level, acceptance is
difficult. A nurse could be of assistance by telling the bereaved, "What happened?" The bereaved person
is given the opportunity to tell his or her side of the story. Every time the tale is told, the bereaved person
gains from confronting the loss and eventually coming to terms with it. The next step in mourning is to
"experience the loss's pain" . It is important for healing to feel and convey strong emotions. The nurse
will evoke a response from the client by inquiring about a loved one. Mourners who have never grieved
before may be surprised by their own reactions. Uncertainty about one's thoughts and feelings will add to
the tension of an already stressful situation. The nurse will remind you about common post-loss emotions
like anxiety, rage, guilt, ambivalence, and depression, as well as the importance of expressing those
emotions. The nurse will teach the client about natural responses to death if the client shows remorse.
“After the death of a loved one, many people have regrets. These are typical responses.”(D, 2018)
Family members must gradually “adjust to a world where the deceased is missing”. This job can
be made simpler by aiding the client in thinking about ways to memorialize their loved one. (Houck,
2014) This allows the deceased to be a part of their new life. The nurse will help bereaved people to chat
about how they're dealing with the changes in their lives. Clients may have issues such as, “What do I do
about his or her possessions?” Since these questions have no correct or wrong responses, the nurse should
encourage problem-solving action by asking, “What have you considered doing?” The nurse will assist
the mourner by normalizing their emotions. “How should I sleep in our bed alone?” asked an older adult
client whose husband had died. The nurse can assure the client that difficulty sleeping is a common
response to loss that gradually resolves. If sleeplessness does not begin to improve, the nurse can assess
the client’s need for referral for additional assistance. Grief, when permitted, helps process the pain of
loss and allows for the pain to heal.

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 As a nurse, you have the privilege of caring for the neediest people. This involves all patients and
their loved ones who have experienced a loss. It's crucial to know the telltale signs of grief and loss and
react appropriately. It is crucial for the nurse to begin this phase by developing a rapport with the patient
and any immediate family members. Encourage them to share their mental and physical feelings freely
and honestly. Active listening skills should be used, as well as a nonjudgmental setting. The NURSE
strategy, developed by the American Association of Critical Care Nurses, is a tool for therapeutic
communication during emotional discussion topics. Using the NURSE pneumonic when engaging with
people who are grieving will help you demonstrate empathy and establish rapport, as seen in the example
below:

When a family member comments: “This is overwhelming.”

The nurse may respond:

 Name: “You feel overwhelmed.” – Name what they just said.

 Explore: “What is the hardest part?” – Further the conversation with an open-ended question.
 Support: “I’ll be here with you all shift.” – Show them that you are there for them.
 Understand: “There is so much going on, how can I help you?"
 Respect: “I’m really impressed with how well you are handling everything.” – Express your
respect for them in this situation.
These techniques can be used individually or as a bundle (Toh et al., 2020). 

It is important for the nurse to support the patient and their loved ones in dealing with their grief,
which may involve anticipatory grief. Educate them on what to expect, such as the stages of depression
and common emotions, as well as tools to help them cope with the loss they are experiencing. Examine
how they are coping with the situation and discuss any grief-related fears. Grief affects people differently,
but it may manifest itself in a variety of ways, including altered immune responses, anxiety, indignation,
sleep disturbances, withdrawal, pain, panic, and suffering. It could be shown by a lack of comprehension
of death, as well as the gravity and finality of the loss. At the bedside, encourage loved ones to try to look
after their own health. Remind them or assist them in receiving food and water. Encourage restful sleep
and proper grooming. It's important to be able to give your patients and their families tools to help them
adapt to their loss and move through the healing process. Chaplain programs, their own clergy or spiritual
support, psychiatric referrals, individual counseling, group therapy, neighborhood peer support groups,
and social work referrals are all possibilities (Rezaei et al., 2020).

Anticipatory grief is grief that occurs before a loss occurs. This method of mourning allows the
patient and their loved ones to start the grieving process together. When a patient receives a terminal
illness diagnosis or undergoes a scheduled amputation surgical operation, this is common. When the

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feelings of loss are overwhelming and do not change for a long period of time, it is referred to as
complicated grief. There is no fixed time for going through the stages of grief; however, in a traditional
grief experience, there is a general movement toward development and healing. One year is a widely
recognized period of time. In complicated grief, the painful feelings overwhelm the person to the point
that they are unable to recover from the loss and regain their life. Normal grief and complicated grief look
very similar in the first few months following a loss; however, complicated grief is more likely to
intensify rather than diminish with time. Individuals dealing with complex grief also need assistance and
services in order to reclaim a sense of acceptance and peace. (Norouzadeh, Anoosheh and Ahmadi, 2020)

5. Clinical Significance

The patient and their loved ones' goals of treatment are to be free of complex grief and to have
enough support to allow for the normal mourning process. It is important that they verbalize and share
their true feelings, as well as seek assistance and encouragement from others. They would be better able
to recognize their own strengths and weaknesses if they do so. It is important that they make use of the
tools available to them in order to manage their grief and comprehend the sense of their loss so that they
can continue to live their new lives

6. Literature review

5.1. Challenges in communicating empathically with patients

Six challenges in communicating empathically with patients were discussed: 1) dialectic tensions
in providing empathy; 2) burden of carrying bad news; 3) lack of skills for providing empathy; 4)
perceived institutional barriers in providing empathy; 5) challenging situations; and 6) perceived
differences. Further, each type of communication challenge included a subset of challenges described
below. Table 1 summarizes themes and sub-themes for challenges in communicating empathically with
patients, and provides additional supporting quotes.

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i. Dialectic tensions in providing empathy

The conflicting emotions of the nurse–patient relationship are referred to as dialectic tensions.
Two types of dialectic tensions were listed by the nurses in this study. For starters, providing empathy
was hampered by the tension between understanding and not knowing about the illness experience.
Despite the fact that nurses' clinical experience provided them with detailed knowledge of what patients
go through while in the hospital, Many nurses felt unqualified to comment or provide a valid opinion on a
patient's problems because they lacked direct personal knowledge. One of the nurses put it this way:

“My lack of personal experience as an in-patient would be a barrier to empathizing with my

patients. I can only imagine the feeling of lack of control and anger, but I don't have any personal
experience with it.”

Second, a nurse's willingness to strike a balance between attachment and separation was cited as
an obstacle to offering empathy when the nurse was torn between their own feelings of attachment to their
patients and their families and the need to retain a degree of detachment from them. One of the nurses, for
example, said,

“I think the biggest challenge is keeping a safe distance and not becoming too involved with
certain issues, so that you can be supportive without becoming sad or upset yourself.”(Testoni et al.,
2020)

ii. Burden of carrying bad news

Nurses usually have access to details about a patient's medical condition in a hospital setting.
Empathic communication is identified as a significant challenge when knowledge is held that has not yet
been revealed to the patient. Nurses spoke about three facets of the tension and pressure they experience
when they have more knowledge than the patient and/or family members in this research. For starters,
nurses were uncomfortable having tough discussions when the patient and family brought up difficult
subjects ahead of time, leaving the nurse feeling unprepared to answer questions. One nurse, for example,
said,

“… bringing up end of life topics before patient is actively dying.”

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 Second, nurses addressed the complexities in sharing information to patients and their families
when the patient's disease status, prognosis, or condition has changed. Nurses spoke about how stressful it
is to have a long-term relationship with a patient, However, since the oncologist has not yet revealed the
details, they are unable to share the correct medical information they have. For example, as one nurse put
it, (Testoni et al., 2020)

“… differences in what I know/expect for a patient and how much/honest a doctor has been with
the family & patient.”

Third, nurses identified their frustration and lack of communication skills when interacting
empathically during transitions to palliative care, such as “when there is nothing else the medical team
can give for care;” as well as facilitating and carrying out EOL conversations, including discussions
surrounding “advanced directives.”(Testoni et al., 2020)

iii. Lack of skills for providing empathy

Empathy communication necessitates the ability to use the right terms and phrases to convey
comprehension of the patient's condition and reassuring the patient that their emotional reaction is true
and rational. Nurses identified five different types of unique communication issues that occur as a result
of a lack of empathy skills. Firstly, nurses shared the absence of skills in knowing what the right response
should be in certain situations. For example,

“I never know what to say … I know I just need to listen sometimes but find it hard to say the
right thing to let them know they can vent or share concerns.”

“A challenge I feel is when they know they are dying and have just given up hope what to say to
them.”

Second, some nurses expressed a lack of ability in selecting suitable terms to convey empathy
rather than "sympathy" or "pity." They also spoke about their fear of sounding shallow or using insincere
words, such as:

“Knowing if what your saying is understood by patient. Knowing that in the end everything you
say can’t change the bad news. I feel like I’m just spewing clichés.”

Thirdly, some nurses conveyed the lack of skills in communicating empathy when the patient
and/or their family is unresponsive or unwilling to listen to the nurse, such as,

“Will they understand I am being empathetic? Am I conveying this to them? They don’t verbalize
this kind of thing.”
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 A fourth theme concerned a lack of expertise in recognizing patients' individual needs and
providing care tailored to their specific needs. A couple of nurses replied that while it is difficult to
accept, it is important to note that as nurses, they have seen many patients who are experiencing
emotional distress or other issues. Patients, on the other hand, may be experiencing their first
hospitalization for cancer. As a result, giving each patient individual attention and having empathic
contact can be challenging for nurses at times, and nurses want to be well-equipped to do so. Finally, a
few of the nurses mentioned that their lack of medical experience made it difficult for them to really
comprehend the situation and provide empathic support.

iv. Perceived institutional barriers in providing empathy

Another topic that came up in discussions about empathic communication issues was nurses'
perceptions of institutional barriers. Two obstacles in particular were addressed. To begin with, a lack of
time to sit with the patients hampered the provision of empathic help. Many nurses expressed this
concern, and it stood out as one of the major roadblocks. As an example:

“Challenges in communicating empathetically with my patients include a lack of time, for

example, if it is a busy night on the unit and time spent with patients is limited.”

Second, a couple of the nurses spoke about how the medical staff and the patients and families
have different expectations of them, making it difficult for them to provide empathic help. One of the
nurses spoke about how she was unable to communicate empathically with patients because the medical
staff on her floor was always focused on treating the clinical symptoms. Therefore, she found it awkward
to communicate with the patient when other members of the team do not worth communication and line
up clinical issues.

v. Challenging situations

Nurses described four types of challenging situations that made empathic communication difficult:
angry patients/families, disrespectful patients/families, when patients/families are unable to accept EOL
and are very distressed, and families that are struggling with their own issues and are not open to having
communication with the nurse. The following excerpts exemplify these communication challenges
respectively,

“When patients and families are stand-offish and aggressive at times.”

“… it can be more difficult to empathically communicate with a patient when they are verbally
abusive and impatient.”

“… they are not emotionally ready to let go of dying family member.”

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 “Family members with conflicting views.”

5.2. Challenges in discussing death, dying and end-of-life (EOL) goals of care

Five challenges in discussing death, dying and EOL goals of care were discussed: 1) dialectic
tensions in EOL discussions; 2) challenges in discussing specific topics related to EOL; 3) lack of skills
for empathic communication during EOL care; 4) patient/family characteristics; and 5) perceived
institutional barriers in EOL care. Table 2 summarizes themes and sub-themes for challenges in
discussing death, dying and EOL goals of care, and provides additional supporting quotes.

5.2.1. Dialectic tensions in end-of-life discussions

Dialectic tensions, as previously said, relate to the nurse-patient relationship's conflicting desires. When
asked about EOL difficulties, nurses discussed two types of dialectic tensions: the balance between
attachment and separation, and the balance between informing the family and withholding information.
To begin, there was a discussion about equilibrium versus attachment and separation, with some nurses
saying that they shape relationships with their patients and often become emotional during discussions
about end-of-life treatment. These talks either activate their own fears of dying or result in counter-
transference, in which the nurse becomes too interested in the patients' fears, worries, sorrow, and other
emotions. (Puntillo et al., 2001)

The next dialectic dispute was about striking the right balance between informing the family and
hiding information because the practitioner had not told the patient or the family. Several nurses
mentioned circumstances in which a physician's personal frustration with having EOL discussions
stopped them from having these conversations with patients and their families. This hesitation on the part
of physicians often prevented nurses from initiating EOL conversations, even when the prognosis
appeared to be grim and the physician's presence was required. For example, "the practitioner's own
unease and aversion to discussing the probability or certainty of death."

5.2.2. Challenges in discussing specific end-of-life topics

EOL interactions necessitate proficiency in describing the "transition to palliative care," the principles of
"natural death," "comfort care," and "EOL goals" with the appropriate terms and phrases. Nurses
identified four distinct types of communication problems that occur as a result of a lack of skills in
addressing specific EOL topics. To begin, nurses stated that they lacked the ability to communicate the
reasons for transitioning to palliative care/comfort care, as well as to respond to patient and family
emotions and questions about the transition process. “Explaining to the family that it is about making the
patient comfortable,” for example: (Challenges in...) Explaining why we're discontinuing a ton of
medications.”

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The second theme dealt with the difficulty of determining patient/family needs and preparation for EOL
discussions, as well as initiating such discussions. One nurse mentioned the difficulty of checking in with
the patient to see if he or she was aware of the bad prognosis, and another nurse mentioned the difficulty
of beginning an EOL conversation. (Rezaei et al., 2020)

“Getting to know the patients expectations – are they aware of the poor prognosis?”

“Where to even begin. Can’t assume that they don’t ever want to talk about death. Just getting the
conversation started and knowing when the right time is for the patient.”

Third, some of the nurses identified specific topics related to the idea of "natural death," as well as EOL
objectives, imminent death (approaching death), and timing of death, as a challenge. When the patient or
family members ask pointed questions about their death, such as "when?" and "how?" a few nurses
reported feeling uncomfortable. These discussions were difficult for the nurses, who said the ideas of
"body shutting down" and "natural process of dying" were difficult to understand. For example, "it's
difficult to convey to family members that this is normal or how the body functions at the end of life..."

Finally, a few of the nurses expressed discomfort when addressing grief and bereavement issues, such as:
(Challenges in...) “What loved ones should do to help them cope after a loss.”

5.2.3. Lack of skills for providing empathy during end-of-life care

Nurses identified three difficulties in providing empathy in EOL scenarios: not knowing what to
say, dealing with fear and other emotions, and appropriately providing empathy. To begin, nurses
identified a complete lack of words in emergency situations (such as "not knowing what to say," or
"choice of words...") when patients and family members want to know their current condition and
prognosis. Second, there are difficulties in dealing with patient emotions such as death fears, rage, grief,
They find it difficult to communicate effectively because of their grievances and disappointments. Some
nurses described anticipating patients' emotions when the doctor delivers bad news and handling patient
emotions at the end of life as difficult. One nurse said it's difficult for her to empathize with patients
because of the "look on their face." According to another nurse,

“The most difficult aspect is how they are going to receive the message and react, because
everyone sees death differently.”

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Finally, some of the nurses identified the difficulties in communicating acceptable levels of empathy
without coming across as preachy or pitying. “How do I be matter-of-fact while still showing sympathy?”
for example. Should I show sympathy or would that come across as pity?”

5.2.4. Patient/family characteristics

Specific features of patients and families that make contact difficult for nurses are referred to as
patient/family characteristics. Pediatric patient environments, young patients with small children, families
not ready to let go, and the patient's cultural values were all identified as patient/family characteristics. To
begin, nurses discussed the difficulties of interacting effectively with pediatric patients. “Discussing them
with families of children dying, and children themselves,” the next two excerpts illustrate the difficulties.

“Talking to a young patient or their parents about it.”

Second, some nurses noted that coping with a young family, where the patient has a young wife or
young children, can be challenging due to the patient's age and vulnerability. Finally, some nurses
addressed the difficulty of coping with a patient or family who is unable to let go or who has not yet
acknowledged the fact of impending death. “It's also very difficult to address dying with patients who
were totally unprepared or did not realize they'd be facing death too quickly (or pts/families who are in
denial),” one nurse explained the difficulties in coping when the family seemed to be in denial and unable
to let go so soon.

Finally, some nurses noted that the difference in cultural beliefs and social values (without
providing any specific examples) of the patient and themselves made communication challenging.
(Gonella et al., 2020)

5.2.5. Perceived institutional barriers in end-of-life care

The nurses' own perceptions of institutional barriers emerged as a final theme in the difficulties
with EOL communication, and they identified two forms of institutional barriers. To begin with, contact
was hindered by tangible obstacles such as a perceived lack of time or a lack of room in the hospital to
have private conversations about EOL. Second, some nurses addressed the difficulty of interacting when
they were unable to make independent decisions about having certain types of conversations with
patients/families due to a lack of medical team approval, such as,

“The feeling that the consent of the medical team has not been granted to nursing staff to discuss these
issues.”

7. Conclusion:

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 In conclusion, this project provides a description of the communication competencies that are faced
by nurses and medical providers in situations like life losses as well as challenges experienced by some
nurses at a given institution. The challenges numbered by nurses also validate findings from other
studies; therefore, describe key obstacles to supportive nurse-client communication.

8. References:

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